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MATTRESS CARE
Name
*
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Last
Address
*
Street Address
Address Line 2
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Congo, Republic of the
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Panama
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Virgin Islands, U.S.
Yemen
Zambia
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Country
Tel
Cell
*
Email
*
Date of Birth
Purchase Date
*
Is this your first Simmons Purchase
Yes
No
If this is a replacement, are you replacing?
Simmons
Sealy
Slumberland
Edblo
Serta
Why did you purchase a new bed at this time?
Current bed old/worn out
Needed additional/larger bed
Medical back problems
Dissatisfied with current bed
In which room will you use your Simmons mattress?
Main Room
Child's Room
Guest Room
Did you intend on purchasing Simmons?
Yes
No
Which best described your family monthly income?
Under R5 000
R5 000 - R10 000
R10 000 - R15 000
R15 000 - R20 000
R20 000 - R30 000
Over R30 000
Residence Ownership
Rented
Owned
Which is your favourite?
TV Channel
Radio Station
Magazine
Newspaper
Education Level
Grade 12
Tertiary Degree
Mattress Information
Model of Simmons Mattress Purchased?
*
Type
Base
Base & Mattress
Size
Single
3/4
Double
Queen
King
Xtra Lenght
Type of Store purchased
Furniture Chain
Cat/Direct Mail
Speciality Sleep
Independent
Hyper Store
Store Details
Price
Name
Branch
Invoice Number
Reason you chose Simmons (Tick 2)
Reputation/Quality of Simmons
Previous Experience Simmons Product
Recommendation of Friend/Family
Recommendation of Salesperson
Recommendation of Physician
Style
Appearance
Comfort
Saw on TV
Saw on Advert
Sale/Promotion
Heard on Radio
Price